Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study

BMJ Open Quality

article

Jane de Lemos¹  Peter Loewen²  Cheryl Nagle³  Robert McKenzie³  Yong Dong You⁴  Anna Dabu⁵  Peter Zed²  Peter Ling⁴  Richard Chan⁶ 

[1] Pharmacy , Richmond Hospital;Faculty of Pharmaceutical Sciences , The University of British Columbia;Family Physician;Internal Medicine , Richmond Hospital;Internal Medicine , Nanaimo Regional General Hospital;Emergency Department , Richmond Hospital

关键词: adverse events;    epidemiology and detection;    root cause analysis;    medication safety;    emergency department;   

DOI  :  10.1136/bmjoq-2020-001161

学科分类：药学

来源: BMJ Publishing Group

【 摘 要 】

Objectives To identify root causes of preventable adverse drug events (pADEs) contributing to hospital admission; to develop key messages which identify actions patients/families and healthcare providers can take to prevent common pADEs found; to develop a surveillance learning system for the community.Methods Cross-sectional observational study; 120 patients and families, 61 associated healthcare providers were interviewed then root cause analysis was performed to develop key learning messages and an electronic reporting tool was designed. Most common pADE-related medical conditions and their root causes and most common pADE root causes of entire cohort are reported.Results Most common pADE-related medical conditions: chronic obstructive pulmonary disease/asthma (13.3%), bleeding (12.5%), hypotension (12%), heart failure (10%), acute kidney injury (5%) and pneumonia (5%). Most common root causes were: providers not confirming that the patient/family understands information given (29.2%), can identify how a medication helps them/have their concerns addressed (16.7%), can identify if a medication is working (14.1%) or causing a side effect (23.3%); can enact medication changes (7.5%); absence of a sick day management plan (12.5%), and other action plans to help patients respond to changes in their clinical status (10.8%); providers not assessing medication use and monitoring competency (19.2%). Ten key learning messages were developed and a pADE surveillance learning system was implemented.Conclusions To prevent pADEs, providers need to confirm that patients/families understand information given, how a medication helps them, how to recognise and respond to side effects, how to enact medication changes and follow action plans; providers should assess patient’s/families’ medication use and monitoring competency.

【 授权许可】

CC BY-NC|CC BY|CC BY-NC-ND